One of the banes of our culture’s psychiatric ideology is its tendency to pathologize mental health difficulties as “disorders” and “diseases”, both of which imply that there’s something wrong with a person that needs to be fixed. This often leads someone diagnosed with a disorder to self-shame, self-blame, and try to fight against their symptoms. In this article, I’ll investigate the notion of disorders and argue that they are actually processes that, as trauma expert Gabor Maté eloquently states, are “normal responses to abnormal circumstances”.
The Dreaded Disorder
Complex PTSD (CPTSD) derives its name, of course, from PTSD, which was begrudgingly added to the DSM-III in 1980. PTSD was the first diagnosis in the DSM for which the cause – severe trauma – was accepted as being external to the person. Despite this, it was still named a disorder, consistent with the vast majority of the other diagnoses in the DSM which were (and still are) largely considered biological in origin.
Particularly with CPTSD, it’s interesting to consider the use of the term disorder and ponder what it reflects about how we view mental health conditions in general.
With respect to mental health, the term disorder – while it has a softer feel than older descriptors such as insane, deviant, or mentally ill – nonetheless carries with it the negative connotations mentioned in the introduction. In addition, when a person has a disorder, the typical next step is that we must figure out how to get rid of it. (Or, most often, its symptoms.)
The implication is that the disorder is a thing to be eliminated – an entity somehow separate from the person who “has” it.
Viewing it as a process, on the other hand, can be much more useful. It eliminates the notion of a condition being a thing – a noun – and instead recognizes it as a verb – dynamic and unfixed. For example, we typically say that someone has depression as if it’s a static entity inside of them. But consider if, instead, we say someone is experiencing depression. While at first, this may appear to simply be a subtle shift in wording, it’s actually a dramatically different way of viewing mental health.
So what exactly are these dynamic processes? To shed some light, we must trace them back to their causes. With CPTSD (along with virtually any other mental health condition), the symptoms that manifest are, in my view, actually a collection of coping strategies that kicked in during childhood due to trauma. These adaptations are highly intelligent when they first come online – they prevent our traumatic experiences from becoming even worse, and in many cases actually save our lives. Once the trauma is over, however, they often become maladaptive and outlive their usefulness.
As a fairly straightforward example, consider someone who is chronically hypervigilant – always on alert for threats, always stressed, and always anxious. Rather than seeing this as something genetic or random, labeling it CPTSD recognizes that it’s the result of childhood trauma – the child adapted to a prolonged lack of safety in its environment by becoming hypervigilant.
This coping strategy is extremely beneficial while the trauma is occurring, but then becomes harmful once the trauma is over.
This type of thing can also be more subtle. Consider someone who is a people-pleaser – chronically putting the needs of others ahead of themselves, and focusing on the happiness of others at the expense of their own. This is a well-known manifestation of CPTSD. In virtually all cases it can be traced back to chronic childhood trauma. For example, a child learns that she has to please her parents in order to be loved, and adapts accordingly. Her #1 priority becomes constantly adjusting and suppressing her behavior, emotions, reactions, and impulses in order to be as pleasing as possible to her parents. Even the slightest prospect of disappointing them becomes a matter of survival and therefore generates extreme amounts of stress. As an adult, this coping strategy continues, now directed towards everyone in the person’s life – her spouse, co-workers, and other family members. The adult becomes obsessed with keeping others happy, and terrified of letting them down.
The only difference between these two examples is that, from Western medicine’s perspective, the first one is diagnosable (i.e. it’s in the DSM) and the second one isn’t. But when we step away from this superficial distinction, we can see the same fundamentals at work: Both of these dynamics are the result of childhood adaptations that become very harmful to a person in adulthood, causing high levels of stress and anxiety which eventually take a toll on their physical bodies as well. Both are the result of trauma, and both are processes that were, at first, highly effective coping strategies.
Implications for Treatment
The notion of a disorder tends to create an attitude that symptoms are something to be gotten rid of – to battle against using any means necessary. Far from being compassionate, this approach essentially puts the internal system at war with itself. The process perspective, on the other hand, opens the door to treatment modalities such as Internal Family Systems (IFS), which work with our coping strategies rather than against them, using self-compassion and understanding. IFS respects that coping strategies came about for good reasons, and therefore doesn’t attempt to change behaviors directly. Instead, a bottom-up approach is used to heal and release a person’s trauma, at which point behavioral change comes about as a natural outcome.
Developmental trauma doesn’t create disorders – it creates coping strategies, which are processes rather than discrete things. Complex post-traumatic stress is what trauma victims suffer from – adding disorder to the name is unhelpful. This shift in perspective is, in my experience, highly effective at enabling clients to look at themselves in a more compassionate and respectful way. Treatment approaches such as IFS – which go beyond the level of the cognitive – can then be used to work with a person’s processes in a balanced and holistic fashion.